The idea that it might be possible to be overweight or obese but not at increased risk of heart disease, otherwise known as the “obesity paradox”, has been challenged by a study of nearly 300,000 people published in in the European Heart Journal.

This latest research shows that the risk of heart and blood vessel problems, such as heart attacks, strokes and high blood pressure, increases as body mass index (BMI) increases beyond a BMI of 22-23 kg/m2. Furthermore, the risk also increases steadily the more fat a person carries around their waist.

The study was conducted in 296,535 adults of white European descent who are taking part in the UK Biobank study, and who were healthy at the time they enrolled with the study. UK Biobank recruited from 2006 to 2010, and follow-up data on participants were available up to 2015 for this latest analysis.

Researchers at the University of Glasgow (UK) led by Dr Stamatina Iliodromiti, a clinical lecturer in obstetrics and gynaecology and MRC Fellow, found that people with a BMI between 22-23 kg/m2 had the lowest risk of cardiovascular disease (CVD). As BMI increased above 22 kg/m2, the risk of CVD increased by 13% for every 5.2 kg/m2 increase in women and 4.3 kg/m2 in men.

Compared to women and men with waist circumferences of 74 and 83 cm respectively, the CVD risk increased by 16% in women and 10% in men for every 12.6 cm and 11.4 cm increase in waist circumference for women and men respectively. Similar increases in CVD risk were seen when the researchers looked at waist-to-hip and waist-to-height ratios and percentage body fat mass – all of which are considered reliable ways to accurately gauge the amount of fat a person carries, also known as adiposity.

Although it is already known that being overweight or obese increases a person’s risk of CVD, as well as other diseases such as cancer, there have also been studies that have suggested that, particularly in the elderly, being overweight or even obese might not have any effect on deaths from CVD or other causes, and may even be protective, especially if people maintain a reasonable level of fitness. This is known as the “obesity paradox”.

However, the authors of the EHJ study say their results refute these previous, conflicting findings. “Any public misconception of a potential ‘protective’ effect of fat on heart and stroke risks should be challenged,” said Dr Iliodromiti.

She continued: “This is the largest study that provides evidence against the obesity paradox in healthy people. It is possible that the story may be different for those with pre-existing disease because there is evidence that in cancer patients, for instance, being slightly overweight is associated with lower risk, especially as cancer and its treatments can lead to unhealthy weight loss.

“By maintaining a healthy BMI of around 22-23 kg/m2, healthy people can minimise their risk of developing or dying from heart disease. In terms of other adiposity measures, the less fat, especially around their abdomen, they have, the lower the risk of future heart disease.”

However, the researchers recognise that it can be difficult for some people to maintain a BMI of 22-23 kg/m2, particularly as they get older. Co-author, Naveed Sattar, Professor of Metabolic Medicine at the University of Glasgow, said: “We know many cannot get to such low BMIs so the message is, whatever your BMI, especially when in the overweight or obese range, losing a few kilograms or more if possible, will only improve your health. There are no downsides to losing weight intentionally and the health professions needs to get better at helping people lose weight.”

The researchers say their findings may have implications for guidelines on preventing and managing cardiovascular disease.

“Even within the normal BMI category of between 18.5-25 kg/m2, the risk of CVD increases beyond a BMI of 22-23 kg/m2. The other adiposity measures show that the leaner the person the lower the risk of CVD, and this must be a public message, that healthy individuals should maintain a lean physique to minimise their risk of CVD,” concluded Dr Iliodromiti.

The researchers suggest that the previous confusion over the “obesity paradox” may be due to many factors that can confound results of studies. For instance, smoking changes the distribution of fat in the body, smokers may have lower weight as smoking depresses appetites and so BMI tends to be lower. Another reason could be that some people have existing but undiagnosed disease, which can often lower their weight but also makes them more likely to die prematurely.

A pill combining low doses of three blood pressure-lowering medications significantly increased the number of patients reaching blood pressure targets compared with usual care, researchers reported at the American College of Cardiology’s 67th Annual Scientific Session. There was also no significant increase in adverse effects with the “Triple Pill.”

“Most people—70 percent—reached blood pressure targets with the Triple Pill. The benefits were seen straight away and maintained until six months, whereas with usual care control rates were 55 percent at six months and even lower earlier in the trial,” said Ruth Webster, MBBS, of The George Institute for Global Health at the University of New South Wales in Sydney, Australia, and lead author of the study. “Based on our findings, we conclude that this new method of using blood pressure-lowering drugs was more effective and just as safe as current approaches.”

Despite the availability of effective blood pressure-lowering drugs, high blood pressure remains a major problem around the world, Webster said. Effectively treating high blood pressure can help to prevent heart attacks, strokes and kidney problems. Globally, however, many people with high blood pressure receive no treatment, and only about a third of those who are treated achieve recommended reductions in blood pressure. Achieving desired reductions in blood pressure often requires treatment with more than one medication, which increases the complexity of treatment, and patients often have difficulty adhering to regimens that involve taking multiple pills every day.

This study was the first large trial designed to test the theory that starting treatment with low doses of three drugs could achieve better blood pressure control compared with usual care and that combining these drugs in a single pill would make it easier both for doctors to prescribe treatment and for patients to adhere to it, Webster said.

The TRIUMPH trial, which was conducted in Sri Lanka, enrolled 700 patients whose average age was 56 years, 58 percent of whom were women. Trial participants had an average blood pressure of 154/90 mm Hg. Over half (59 percent) were receiving no treatment for high blood pressure before they enrolled in the trial. In addition to high blood pressure, 32 percent of participants had diabetes or chronic kidney disease.

Patients were randomly assigned to receive either the combination pill or usual care. The combination pill, or Triple Pill, consisted of the blood pressure medications telmisartan (20 mg), amlodipine (2.5 mg) and chlorthalidone (12.5 mg). These medications use different mechanisms to reduce blood pressure by relaxing the blood vessels, so the heart does not need to pump as hard to send blood throughout the body. Usual care meant that patients received their doctor’s choice of blood pressure­-lowering medication.

The trial’s primary endpoint was the proportion of patients who achieved a blood pressure target of 140/90 mm Hg or less (130/80 mm Hg or less in those with diabetes or chronic kidney disease) at six months.

Compared with patients receiving usual care, a significantly higher proportion of patients receiving the Triple Pill achieved their target blood pressure at six months. The average reduction in blood pressure was 8.7 mm Hg for participants receiving the Triple Pill and 4.5 mm Hg for those receiving usual care. At six months, 83 percent of participants in the Triple Pill group were still receiving the combination pill and one-third of those in the usual-care group were receiving at least two blood pressure-lowering drugs.

The maximum difference between the two groups of patients was observed at six weeks after starting treatment, when 68 percent of those receiving the Triple Pill had achieved a blood pressure within their target range, compared with 44 percent of those receiving usual care. This represented a 53 percent reduction in the risk for high blood pressure for patients receiving the Triple Pill, Webster said.

Rates of participants having to change treatment due to side effects were not significantly different in the two groups (6.6 percent for the Triple Pill, 6.8 percent for usual care). This should allay concerns that use of the three-drug combination pill could lead to an unacceptable increase in adverse medication side effects, Webster said.

Each of the drugs used in the Triple Pill has been shown to be highly effective in reducing blood pressure and preventing deaths and illness due to heart disease and strokes, she said. Each drug represents a different class of blood pressure medication and previous studies have shown that combining such drugs results in synergistic effects.

“The most urgent need for innovative strategies to control blood pressure is in low- and middle-income countries,” Webster said. “The Triple Pill approach is an opportunity to ‘leap frog’ over traditional approaches to care and adopt an innovative approach that has been shown to be effective.”

The study’s findings are also important for high-income countries, she said.

“A control rate of 70 percent would be a considerable improvement even in high-income settings. Most hypertension guidelines in these countries do not recommend combination blood pressure-lowering therapy for initial treatment in all people,” she said. “Our findings should prompt reconsideration of recommendations around the use of combination therapy.”

An inevitable consequence of a necessarily unblinded study (where both participants and their doctors know whether participants are assigned to the Triple Pill or usual care) is that doctors might manage patients differently depending on the assigned treatment. However, it is important to note this trial was designed to evaluate a new strategy of care in a real-world setting, Webster said.

To minimize the risk of bias in measuring the main outcomes, the number of patient visits was identical in both groups and all outcomes were standardized and objectively documented, she said.

The researchers are now conducting a follow-up qualitative study to find out what participants and their doctors thought about using the Triple Pill. And they are conducting a cost effectiveness evaluation to determine whether the Triple Pill is a cost-effective solution for blood pressure control.

Recommended targets for blood pressure control vary by country. In the U.S., guidance released in 2017 by the ACC and the American Heart Association recommends initiating treatment if blood pressure exceeds 130/80 mm Hg. European guidelines recommend that treatment should aim to achieve a blood pressure level of 140/90 mm Hg or less.

The combined rate of death from any cause, heart attack or stroke within 18 months was not significantly different in patients with acute coronary syndrome (ACS) who were randomly assigned to receive dual antiplatelet therapy (DAPT) for either six months or at least 12 months after receiving a drug-eluting stent. Patients who were given DAPT for only six months, however, had more than double the risk of a heart attack compared with those treated for at least 12 months, according to research presented at the American College of Cardiology’s 67th Annual Scientific Session.

“Based on our findings, we can’t say that short-term DAPT is safe in patients with ACS who have received drug-eluting stents,” said Hyeon Cheol Gwon, MD, a professor in the Division of Cardiology at Sungkyunkwan University, director of the cardiac center at Samsung Medical Center in Seoul, South Korea, and principal investigator of the study. “We conclude that current guidelines that recommend prolonged DAPT in patients with ACS who are not at excessive risk for bleeding should continue to be followed.”

ACS occurs when blood flow to the heart is suddenly blocked. It may take the form of a heart attack or unstable angina, chest pain that may signal an imminent heart attack. Patients who have had one episode of ACS are at elevated risk for another. ACS is often treated by inserting a small metal tube, or stent, into a blocked artery to keep the artery open, a procedure known as an angioplasty. A drug-eluting stent is a stent that has been coated with a drug to prevent scar tissue from forming inside the artery.

Current guidelines published by the American College of Cardiology and the American Heart Association recommend that ACS patients not at excessive risk for bleeding should be treated with DAPT— aspirin plus clopidogrel or a similar drug such as ticagrelor—for at least 12 months after the implantation of a drug-eluting stent.

However, there is limited evidence that 12 months or more is the optimal duration for DAPT, Gwon said. Two recently reported studies suggested that six months of DAPT might offer similar benefits in terms of reducing patients’ risk for death, heart attack or stroke, bleeding or other adverse events. These studies, however, had too few participants to provide definitive answers, he said.

“This is the largest trial to address the optimal duration of DAPT in patients with ACS,” Gwon said.

The SMART-DATE trial enrolled a total of 2,712 Korean patients with ACS who were undergoing angioplasty. Their median age was 63 years, and 75 percent were male. Patients were randomly assigned to receive either DAPT for at least 12 months (DAPT-12) or DAPT for six months followed by aspirin alone for at least another six months (DAPT-6). The primary endpoint was the combined rate of death from any cause, heart attack or stroke within 18 months after stent insertion.

At 18 months, 63 patients (4.7 percent) in the DAPT-6 group and 56 patients (4.2 percent) in the DAPT-12 group had experienced at least one of the primary endpoint events. Thus, over the entire 18-month follow-up period, DAPT-6 was significantly not worse (or non-inferior) than DAPT-12, Gwon said. Rates of death from any cause were not significantly different in the two groups (2.6 percent in the DAPT-6 group vs 2.9 percent in the DAPT-12 group).

However, the risk of heart attack was 2.4-fold higher in the DAPT-6 group, with heart attacks occurring in 1.8 percent of DAPT-6 patients vs. 0.8 percent of DAPT-12 patients. Moreover, during the period between six and 18 months after stent insertion when patients in the DAPT-6 group were being treated with aspirin only, there was a 5.1-fold risk of having a heart attack in DAPT-6 patients compared with DAPT-12 patients. During this period, patients in the DAPT-6 group also had a 69 percent higher risk of dying from any cause or having a heart attack or stroke.

Limitations of the study, Gwon said, include the absence of blinding— that is, both patients and doctors knew whether a patient was in the DAPT-6 or the DAPT-12 group—and the absence of a group that was randomly assigned to receive a placebo. However, study statisticians and those whose role was to assess outcomes worked independently from those overseeing the trial, he said.

Patients in the trial will be followed for an additional 18 months, for a total of three years of follow-up, Gwon said.

After six months of follow up, women newly diagnosed with breast cancer who were given the beta blocker carvedilol to prevent heart issues while undergoing chemotherapy showed no difference in declines in heart function compared with those taking a placebo. Patients who took carvedilol, however, were significantly less likely to have an elevated marker in the blood that signals injury to the heart, according to a study being presented at the American College of Cardiology’s 67th Annual Scientific Session.\

The study enrolled 200 patients diagnosed with breast cancer who had normal left ventricular ejection fraction and who, as part of their cancer treatment, were scheduled to receive anthracycline (ANT). Patients were randomly assigned to receive either carvedilol (median daily dose of 18.4 mg/day) or placebo when starting ANT chemotherapy (240 mg/m2) until completing it. ANT is a type of chemotherapy that at certain cumulative doses has been shown to cause heart damage by weakening the heart muscle. Carvedilol works by slowing the heart rate, opening blood vessels and improving blood flow, which also lowers blood pressure.

“This is the largest randomized clinical trial of a beta blocker to prevent the toxic effects of contemporary doses of anthracycline [ANT] on the heart,” said Mônica Samuel Avila, MD, assistant doctor in the Heart Failure and Heart Transplant Department in Heart Institute, Clinical Hospital of Medical School of São Paulo, and the study’s lead author. “This is only short-term follow up, but we found that carvedilol seems to prevent myocardial injury, but it did not have an impact on left ventricular ejection fraction.”

Avila also said the study findings further reinforce the need for cardiologists and oncologists to work together to define the best treatment strategies for individual cancer patients that minimize other negative effects, especially to the heart.

Neither the patients nor those administering the treatment knew which patients received carvedilol versus the placebo. Researchers assessed cardiotoxicity by measuring heart function with periodic echocardiograms and blood tests to check for a protein called high-sensitivity troponin T, which is released into the bloodstream when injury to the heart occurs. These measures were tracked at baseline and after each cycle of ANT chemotherapy (three, six, nine and 12 weeks) and after the end of all chemotherapy (around 24 weeks). Patients in the carvedilol and placebo groups were an average of 51 and 53 years of age, respectively. All had finished chemotherapy treatment.

For the study’s primary endpoint, prevention of greater than a 10 percent reduction in left ventricular ejection fraction at six months, researchers found no significant difference between the carvedilol and placebo groups, 14.5 vs. 13.5 percent, respectively. Ejection fraction is a measure of how much blood is pumped out of the heart with each contraction; anything over 55 percent is considered normal. Overall, declines in ejection fraction were minimal in both groups and were not statistically significant (from baseline to 24 weeks the average drop in ejection fraction was 65.2 to 63.9 percent in the placebo group and 64.8 to 63.9 percent in the carvedilol group).

Secondary outcomes included carvedilol’s effects on two biomarkers, troponin I and B-type natriuretic peptide (BNP), and diastolic dysfunction. Of the 65 (33.8 percent) patients with higher plasma levels of troponin I that are known to be suggestive of heart damage, many more were in the placebo group—41.6 percent vs. 26 percent. There was no difference in levels of BNP, a hormone produced by the heart that goes up when heart failure develops or gets worse. While not significant, patients in the placebo group tended to have enlarged hearts, compared to patients in the carvedilol group. Avila said this could indicate that carvedilol may help prevent remodeling or changes in the structure of the heart.

According to Avila, the reason why patients taking carvedilol had lower troponin levels, but no differences in changes in ejection fraction, is difficult to explain. She noted that the six-month follow-up may not have been sufficient to see changes in heart function. In addition, any heart damage may not have been severe enough to lead to heart failure. There was only one case of overt heart failure with reduced ejection fraction, which was in the placebo group.

“Previous studies have shown that higher troponin levels can predict cardiovascular events and so we could imagine that carvedilol may be able to prevent these events, but we did not see this finding in our study,” she said, adding that she and her team will continue to follow these patients and report data at one and two years.

In the meantime, researchers did find the prevalence of cardiotoxicity in this study to be lower than in previously reported data from other studies—a finding that could be attributed to lower doses of anthracyclines and lower overall cardiovascular risk in the study population. It could be that the beneficial effect of carvedilol might be more pronounced among higher risk patients, Avila said. In recent years, lower doses of anthracyclines are used to help reduce the risk of heart damage from treatment.

Source: American College of CardiologyFull bibliographic information:Carvedilol for Prevention of Chemotherapy Related CardiotoxicityJournal of the American College of Cardiology

Treatment with dabigatran significantly reduced the risk of death, heart attack, stroke and other heart or blood-vessel complications among patients who were at elevated risk for these events because of heart damage that occurred after major noncardiac surgery, according to research being presented at the American College of Cardiology’s 67th Annual Scientific Session.

In the first randomized controlled trial to evaluate a treatment for myocardial injury after noncardiac surgery (MINS), researchers found that patients treated with dabigatran twice daily were 28 percent less likely to die, have a heart attack or stroke, develop blood clots or need an amputation due to cardiovascular disease, compared with patients who received a placebo.

“We have shown for the first time that dabigatran reduces the risk of major cardiovascular complications and offers an option for improving outcomes in a large at-risk population who have MINS,” said P.J. Devereaux, MD, PhD, director of cardiology at McMaster University in Hamilton, Canada, and lead author of the study.

Approximately 8 million people every year develop MINS after undergoing surgery such as a hip or knee replacement, bowel resection or abdominal aortic aneurysm repair.

This study builds on research that Devereaux and his colleagues presented at the American College of Cardiology’s 66th Annual Scientific Session in 2017 showing that MINS may account for about 1 in 4 deaths during the first 30 days after surgery. That research also showed a blood test for a protein called high-sensitivity troponin T, which is released into the bloodstream when injury to the heart occurs, can identify patients with MINS whose lives could potentially be saved with timely treatment.

Most cases of MINS currently go undetected, Devereaux said, because at present it is not standard practice in most centers to monitor blood levels of troponin in patients who had major noncardiac surgery. Devereaux said he is hopeful this will change now that this study has shown treatment with dabigatran can improve outcomes for patients with MINS.

“Our findings reaffirm that patients who develop MINS are at high risk for bad outcomes,” he said. “We owe it to our patients to identify this risk and do what we can to reduce it.”

The study enrolled 1,754 patients in 19 countries, 51 percent of whom were men, with an average age of 70 years. The primary efficacy outcome was the combined rate of death from a cardiovascular cause, heart attack, stroke due to inadequate blood supply, blood clots or amputation due to cardiovascular disease. The primary safety outcome was the combined rate of life-threatening, major and critical organ bleeding. During the study, patients, health care providers and research staff were blinded to which group received dabigatran and which received a placebo.

After an average follow-up of 16 months, 11.1 percent of patients treated with dabigatran experienced one or more of the primary efficacy outcome events, compared with 15.2 percent of patients who received a placebo. This translates to a 28 percent reduction in risk for patients receiving dabigatran.

When researchers analyzed occurrence rates for the events comprising the primary efficacy outcome, they found trends of benefit for each component. For example, patients treated with dabigatran were 20 percent less likely to die of a cardiovascular cause, 20 percent less likely to have a heart attack, 30 percent less likely to have an amputation and 53 percent less likely to have a venous blood clot than patients who received a placebo. The result for nonhemorrhagic stroke also demonstrated a benefit with an 80 percent reduction in risk, a difference that was statistically significant compared with patients who were randomized to placebo.

There were no statistically significant differences between the two groups in life-threatening, major or critical organ bleeding. Compared with the placebo group, however, more patients in the dabigatran group experienced bleeding in the lower gastrointestinal tract and minor bleeding.

An increased risk of bleeding is an expected complication of treatment with a blood-thinning medication.

“It’s encouraging that we did not see an increase in major or life-threatening bleeding in patients on dabigatran,” Devereaux said.

Researchers noted that while nearly all patients (98.9 percent) completed follow-up, 45.3 percent of those on dabigatran had discontinued the study drug. The most common reason for drug discontinuation was patient request; however, 14 percent of these patients had a major complication (e.g., heart attack, stroke, bleeding). According to Devereaux, analyses that counted patients up to seven days after they discontinued the study drug showed even larger treatment effects, with 46 percent reductions in major cardiovascular complications with dabigatran and no excess of life-threatening, major or critical organ bleeding.

Devereaux said that future research is needed to evaluate other treatment options for this high-risk group of patients.

Getting a large dose of a statin did not have an impact on major adverse cardiac events among a broad population of patients slated to undergo percutaneous coronary intervention (PCI) in a trial being presented at the American College of Cardiology’s 67th Annual Scientific Session. However, statins did significantly reduce the rates of such events among the subset of trial participants who actually underwent PCI.

PCI is one of several treatments for people with acute coronary syndrome, an umbrella term that encompasses heart attacks and unstable angina. In this trial, patients were randomized to receive either a placebo or a “loading dose” of a statin, consisting of two double-doses administered the day before and the day after a scheduled PCI, followed by a daily low-dose of a statin for 30 days.

The trial is the largest study to date aimed at testing the hypothesis that statins could help reduce cardiovascular events around the time of PCI. More than 4,100 patients were enrolled in the trial at 58 centers in Brazil. All patients had acute coronary syndrome for which doctors planned to perform PCI within seven days. However, about one-third of the study participants ultimately did not receive PCI because doctors opted to perform other treatments, such as coronary artery bypass grafting.

Participants in this study were reflective of the broader population of people with acute coronary syndrome, and the study protocols were reflective of common hospital practices, said Otavio Berwanger, MD, PhD, cardiologist and clinical epidemiologist at the Brazilian Clinical Research Institute, Sao Paulo, Brazil, and the study’s lead author. He suggested that the results would likely be applicable in many countries and health care environments. About 70 percent of the patients had never taken statins and about 30 percent had taken them previously or were on low-dose statins when they enrolled in the study. Patients who were already taking a maximum tolerated dose of statins were excluded.

Statins are a widely-used class of drugs that lower LDL, or “bad” cholesterol, thereby helping to prevent serious cardiovascular events in people at high risk for heart disease. In addition to their long-term preventive benefits, basic research suggests statins also may affect processes involved in inflammation and the formation of blood clots.

In this study, half of the participants were randomly assigned to receive two double (80 milligram) doses of atorvastatin—one shortly before the procedure and one within a day afterward. The other half received two doses of a placebo. Neither patients nor their doctors knew who had received the placebo. All patients then took 40 milligrams of atorvastatin daily for 30 days, which is standard practice after acute coronary syndrome.

Among all patients, the primary endpoint occurred in 6.2 percent of those taking the statin and 7.1 percent of those taking the placebo, a difference that was not statistically significant. Among patients who received PCI, the primary endpoint occurred in 6 percent of those taking the statin and 8.2 percent of those taking the placebo, a reduction that was statistically significant.

“Although the trial is negative for our primary endpoint in the full study population, the findings of our prespecified analysis are very consistent with smaller trials and observational studies that suggest a reduction in events in the PCI population,” Berwanger said. “Viewed in the context of the literature, our study helps to confirm what has been shown before and suggests that it can be beneficial to consider giving a loading dose of a statin to patients who undergo PCI.”

Overall, patients who underwent PCI and received a loading dose of statins were 28 percent less likely to experience a major adverse cardiac event and 32 percent less likely to have a heart attack compared with those taking the placebo.

“This study adds another piece to the puzzle,” Berwanger said. “I think it also opens the stage for testing other lipid-lowering agents that may have effects beyond lowering lipids.”

Researchers will continue to track outcomes for 12 months. In addition, the team is planning another trial focused on assessing potential benefits of statins and other drugs in patients undergoing PCI.

Source: American College of CardiologyFull bibliographic information:Effect of Loading Dose of Atorvastatin Prior to Planned Percutaneous Coronary Intervention on Major Adverse Cardiovascular Events in Acute Coronary Syndrome: The SECURE-PCI Randomized Clinical Trial

Brisk walks lasting 40 minutes or more, two to three times per week seem to yield greatest benefit

Walking for at least 40 minutes several times per week at an average to fast pace is associated with a near 25 percent drop in the risk of heart failure among post-menopausal women, according to new research being presented at the American College of Cardiology’s 67th Annual Scientific Session. The benefit appears to be consistent regardless of a woman’s body weight or whether she engages in other forms of exercise besides walking.

About 6.5 million adults have heart failure, a condition in which the heart becomes too weak to pump enough blood to meet the body’s needs. The risk of heart failure rises with age; women 75-84 years of age are three times as likely to have heart failure compared with women 65-74 years old.

“We already know that physical activity lowers the risk of heart failure, but there may be a misconception that simply walking isn’t enough,” said Somwail Rasla, MD, a cardiology fellow at Saint Vincent Hospital, who conducted the study during his residency at Brown University. “Our analysis shows walking is not only an accessible form of exercise but almost equal to all different types of exercise that have been studied before in terms of lowering heart failure risk. Essentially, we can reach a comparable energetic expenditure through walking that we gain from other types of physical activity.”

Because walking can be done any time and doesn’t require special equipment, the results put meaningful physical activity within reach for older women who may be hesitant to join a gym or begin a new workout routine.

The study, which analyzed walking behavior and health outcomes among 89,000 women over a more than 10-year period, is the first to examine, in detail, the benefits of walking by parsing the effects of walking frequency, duration and speed. It is also the first to specifically focus on the risk of heart failure among women over age 50.

The research is based on an analysis of data from the Women’s Health Initiative, a large study funded by the National Heart, Lung, and Blood Institute that collected data about women’s habits and health outcomes from 1991-2005. Participants were between 50 and 79 years of age at enrollment. Rasla and colleagues extracted data for women who, at baseline, were able to walk at least one block and did not have heart failure, coronary artery disease or cancer.

Based on information from participant questionnaires, the women’s walking behavior was categorized according to frequency, duration and speed. Researchers also assessed the women’s overall energy expenditure from walking by combining all three of these variables into a calculation known as Metabolic Equivalent of Task (MET). Those in the highest tertile for MET per week were 25 percent less likely to develop heart failure compared with those in the lowest tertile.

The findings suggest walking frequency, duration and speed each contribute about equally to this overall benefit. Women who walked at least twice a week had a 20 to 25 percent lower risk of heart failure than those who walked less frequently. Those who walked for 40 minutes or more at a time had a 21 to 25 percent lower risk than those taking shorter walks. Women walking at an average or fast pace showed a 26 and 38 percent lower risk of heart failure, respectively, compared with women who walked at a casual pace.

Researchers said the results were consistent across different age categories, ethnicities and baseline body weight in post-menopausal women, suggesting the findings can be generalized to apply to most women above 50 years old.

“We actually looked at women with four different categories of body mass index (BMI) and found the same inverse relationship between walking behavior and the risk of heart failure,” Rasla said. “The results show that even obese and overweight women can still benefit from walking to decrease their risk of heart failure.”

The analysis accounted for a variety of heart disease risk factors, such as smoking, alcohol use, family and medical history, use of hormones and overall amount of physical activity. Walking behavior was assessed based on self-reporting by participants during the study. Researchers were unable to account for the potential effects of exercise or walking habits earlier in life.

Source: American College of CardiologyFull bibliographic information:Association of Walking Pace, Walking Frequency and Duration and Joint Effects on the Risk of Heart Failure in Post-Menopausal Women,American College of Cardiology's 67th Annual Scientific Session.

Listening to upbeat music may help prolong activity and participation; results may have broader implications for exercise in general

If you exercise while listening to music, you may have noticed it can help boost your energy and make your workout seem quicker. Similarly, a study being presented at the American College of Cardiology’s 67th Annual Scientific Session suggests listening to music during a standard cardiac stress test can help extend the time someone is able to perform the test, yielding important information about an individual’s heart health and capacity for exercise.

Music can have a powerful impact on our mood, signaling the brain to release feel-good and energy-boosting chemicals. While earlier studies have looked at how music might influence specific markers of heart health, this study is the first to evaluate its impact on exercise tolerance during cardiac stress testing—widely used to measure the effects of exercise on the heart. On average, people who listened to music during the test were able to exercise for almost one minute longer than those who didn’t have tunes playing in their ears.

“At least on a small scale, this study provides some evidence that music may help serve as an extra tool to help motivate someone to exercise more, which is critical to heart health,” said Waseem Shami, MD, a cardiology fellow at Texas Tech University Health Sciences in El Paso, Texas, and the study’s lead author. “I think it’s something we intuitively knew, but we found [to be true]. I suspect if it had been a larger study, we’d see a bigger difference.”

Cardiac stress tests help doctors evaluate someone’s fitness level or readiness to start an exercise program, measure heart rate and blood pressure responses to exercise, assess symptoms of chest pain or heart rhythm changes during exercise, and help diagnose blockages in the heart’s arteries. They are often done on a treadmill or stationary bike, while a person has electrodes placed on their chest to record the heart’s activity.

In this single-center, randomized study, patients scheduled for a routine electrocardiogram (ECG) treadmill stress test were informed about the study and asked if they would participate. A total of 127 patients (53 years of age on average) were randomly assigned to either listen to up-tempo music (mostly Latin-inspired music) or have no music playing during their stress tests. To “blind” the staff and clinicians, all participants wore headphones during their test. Individuals had similar medical histories, including diabetes and hypertension. The majority of participants were Hispanic, reflecting their patient population. There were more females than males in both groups (61.2 and 66.7 percent in the music and control groups, respectively).

Shami explained that stress tests can be challenging—even painful—for some people because the treadmill speed and incline is increased every three minutes. In the standard Bruce protocol, the starting point (i.e., stage 1) is 1.7 mph at a 10 percent grade (5 METs). Stage 2 is 2.5 mph at a 12 percent grade (7 METs). Stage 3 is 3.4 mph at a 14 percent grade (9 METs). This protocol includes three-minute periods to allow achievement of a steady state before workload is increased.

“After six minutes, you feel like you are running up a mountain, so even being able to go 50 seconds longer means a lot,” he said. Although the maximum duration for a stress test is 20 minutes, Shami said most healthy people usually last for seven to eight minutes.

Exercise time was significantly longer in the music group compared with the control group, 505.8 versus 455.2 seconds, respectively—an absolute difference of about 50.6 seconds. In addition, there was a (non-significant) trend toward longer metabolic equivalent of task (METs) when compared with the non-music group. A MET is a ratio of the rate of energy expended during an activity to the rate of energy used at rest. Generally, the higher the number, the more energy used and the harder someone worked.

There were no differences in how often patients were able to reach their maximal target heart rate goal between the two groups, which was one of the reasons Shami and team designed the pilot study.

Although the study involved people undergoing cardiac stress testing, Shami said he believes the findings could apply to a wider population and help motivate people to follow recommendations for regular exercise for heart health.

“Our findings reinforce the idea that upbeat music has a synergistic effect in terms of making you want to exercise longer and stick with a daily exercise routine,” he said. “When doctors are recommending exercise, they might suggest listening to music too.”

Being inactive or not exercising ranks alongside high blood pressure, high cholesterol, smoking and obesity as one of the five major risk factors for cardiovascular disease. Getting regular exercise may be one of the best defenses against heart disease or having another cardiac event. Experts recommend adults get at least 30 minutes of moderate (aerobic) activity most days; this includes taking a brisk walk, swimming, playing tennis, riding a bicycle, dancing, water aerobics, gardening and even busy housework.

Shami said a larger study with greater diversity is needed to be able to determine whether offering music during stress testing can help people achieve their target heart rate and if it should be recommended as a tool to help people.

Source: American College of Cardiology

Full bibliographic information:Shami will present the study, “Does Music Impact Exercise Capacity During Cardiac Stress Test? A Single Blinded Pilot Randomized Controlled Study,” American College of Cardiology's 67th Annual Scientific Session.

An analysis of medical-record data from more than 17.5 million patients found that people with inflammatory bowel disease (IBD) are at elevated risk for a heart attack, regardless of whether or not they have traditional risk factors for heart disease such as high cholesterol, high blood pressure and smoking. People between the ages of 18 and 24 are at the highest risk, according to research presented at the American College of Cardiology’s 67th Annual Scientific Session.

“Younger patients had about nine times the risk of a heart attack compared to their peers in the same age group [who didn’t have IBD], and this risk continued to decline with age,” said Muhammad S. Panhwar, MD, a resident in internal medicine at Case Western Reserve University/University Hospitals Cleveland Medical Center in Cleveland and lead author of the study, one of the largest to date to investigate the link between IBD and heart disease risk. “Our findings suggest that IBD should be considered an independent risk factor for heart disease.”

IBD is an umbrella term for two chronic inflammatory conditions, Crohn’s disease and ulcerative colitis. Per Centers for Disease Control and Prevention (CDC) data, as of 2015, an estimated three million Americans have IBD and about 70,000 new cases are diagnosed every year. While different studies have shown that people with other chronic inflammatory conditions, such as lupus and rheumatoid arthritis, are at increased risk for heart disease, a link between IBD and heart disease has been under debate.

To investigate a possible link between IBD and heart disease risk, Panhwar and his colleagues used IBM Explorys, a large database of de-identified data from electronic medical records for patients of 26 nationwide health care systems in the U.S. They identified adult patients ages 18 to 65 with a diagnosis of IBD between 2014 and 2017 and looked at how many patients with and without IBD had heart attacks.

Among more than 17.5 million patients in the database, 211,870 (1.2 percent) had IBD, which is comparable to numbers reported by the CDC. People with IBD were also more likely to have diabetes, high blood pressure, high cholesterol and smoking—traditional risk factors for heart disease—than people without IBD.

Compared with patients who did not have IBD, heart attacks occurred roughly twice as often in those with IBD. After adjusting for age, race, sex and traditional heart disease risk factors, Panhwar and his colleagues found that the patients with IBD had about a 23 percent higher risk of having a heart attack.

Women under the age of 40 with IBD were at higher risk for a heart attack than men with IBD in the same age group. In patients over the age of 40, heart attack risk was similar for men and women with IBD.

IBD is usually diagnosed between the ages of 15 and 30 years old, and younger patients and females with this condition are known to have more aggressive and disabling disease with more frequent flares, suggesting increased levels of inflammation. Panhwar said this disproportionate amount of inflammation in younger patients with IBD—who often don’t have traditional cardiovascular risk factors—and women may explain why they had such a markedly higher risk of heart attacks.

“Our study adds considerably to a growing set of literature highlighting the importance of chronic inflammation in IBD as having a role in the development of heart disease,” Panhwar said.

He suggested that physicians who have patients with IBD should be aggressively screening them for heart disease and focusing on risk reduction strategies.

“The results suggest clinicians should take seriously any symptoms suggestive of heart disease, such as chest pain, in patients with IBD, especially in younger patients,” he said.

Even though this was a very large study, there are some limitations. The database lacks granularity regarding the type of heart attack and did not enable the researchers to exclude from the analysis people who had had previous heart attacks and may have, therefore, been at higher risk for another heart attack. Also, the database did not provide information about how individual patients fared over time.

Panhwar said the findings of this study open the field for more research into the link between IBD and heart disease, including the benefit of using anti-inflammatory drugs for the management of cardiovascular risk in patients with IBD. In addition, he expressed hope that the findings will empower people with IBD, especially those under 40 years of age, to have conversations with their doctor about their personal risk of cardiovascular disease.

Source: American College of Cardiology

Full bibliographic information:Risk of Myocardial Infarction in Patients with Inflammatory Bowel Disease,American College of Cardiology's 67th Annual Scientific Session.

Large day-to-day swings in temperature were associated with significantly more heart attacks in a study being presented at the American College of Cardiology’s 67th Annual Scientific Session. Given that some climate models link extreme weather events with global warming, the new findings suggest climate change could, in turn, lead to an uptick in the occurrence of heart attacks, researchers said.

“Global warming is expected to cause extreme weather events, which may, in turn, result in large day-to-day fluctuations in temperature,” said Hedvig Andersson, MD, a cardiology researcher at the University of Michigan and the study’s lead author. “Our study suggests that such fluctuations in outdoor temperature could potentially lead to an increased number of heart attacks and affect global cardiac health in the future.”

There is a large body of evidence showing that outdoor temperature affects the rate of heart attacks, with cold weather bringing the highest risk, but most previous studies have focused on overall daily temperatures. This new study is among the first to examine associations with sudden temperature changes.

“While the body has effective systems for responding to changes in temperature, it might be that more rapid and extreme fluctuations create more stress on those systems, which could contribute to health problems,” Andersson said, noting that the underlying mechanism for this association remains unknown.

Along with an overall warming trend, climate change is projected to lead to more extreme events, such as heat waves and cold snaps, depending on where someone lives, the researchers explained.

The research is based on data from more than 30,000 patients treated at 45 Michigan hospitals between 2010-2016. All patients had received percutaneous coronary intervention, a procedure used to open clogged arteries, after being diagnosed with ST-elevated myocardial infarction, the most serious form of heart attack.

The researchers calculated the temperature fluctuation preceding each heart attack based on weather records for the hospital’s ZIP code. Daily temperature fluctuation was defined as the difference between the highest and lowest temperature recorded on the day of the heart attack.

Overall, the results showed the risk of a heart attack increased by about 5 percent for every five-degree jump in temperature differential, in degrees Celsius (9 degrees Fahrenheit). Swings of more than 25 degrees Celsius (45 degrees Fahrenheit) were associated with a greater increase in heart attack rates compared to a smaller increase with temperature swings of 10 to 25 degrees Celsius (18-45 degrees Fahrenheit). The effect was more pronounced on days with a higher average temperature; in other words, a sudden temperature swing seemed to have a greater impact on warmer days.

At the far end of the spectrum, on a hot summer day, nearly twice as many heart attacks were predicted on days with a temperature fluctuation of 35-40 degrees Celsius (63-72 degrees Fahrenheit) than on days with no fluctuation.

“Generally, we think of heart attack risk factors as those that apply to individual patients and we have, consequently, identified lifestyle changes or medications to modify them. Population-level risk factors need a similar approach,” said Hitinder Gurm, MD, professor of medicine and associate chief clinical officer at Michigan Medicine and the study’s senior author. “Temperature fluctuations are common and [often] predictable. More research is needed to better understand the underlying mechanisms for how temperature fluctuations increase the risk of heart attacks, which would allow us to perhaps devise a successful prevention approach.”

In their analysis, the researchers adjusted for precipitation totals, day of the week and seasonal trends to isolate the effects of daily temperature fluctuations from other potential environmental factors.

Gurm cautioned that the association does not necessarily prove that sudden temperature swings are the cause of the increase in heart attacks; other factors may have contributed to the results. He noted that it remains important to focus on modifiable cardiovascular risk factors such as smoking, high blood pressure and high cholesterol.